THE THERAPIST TOOLBOX FOR MINIMIZING READMISSIONS

Lynn Vanderburg BA, RRT, NRP

Hospital Readmissions Reduction Program (HRRP)

• Legislative Context Shapes HRRP– Patient Protection and Affordable Care Act (2010) was to provide

everyone in America with affordable Health care• Faced stiff opposition• To get it passed programs had to be inserted that would reduce the total

cost burden of the bill– HRRP is one of those cost reduction programs

• Estimated to reduce Medicare payments by $7.1 billion (between 2013-2019)

http://www.santarosaconsulting.com/santarosateamblog/post/2012/03/29/an-early-look-at-hospital-readmissions-reduction-program

Hospital Readmission Reduction Program

• Brief overview– The HRRP is a reimbursement penalty approach for general acute

care hospitals that have readmissions deemed “excess” by CMS• Began fiscal year 2013 (October 1, 2012)• Reduction is capped at 1% in 2013, 2% in 2014 and 3% in 2015 and

beyond• Reductions apply to total DRG reimbursement

– But readmissions deemed excess are determined using 3 specific conditions endorsed by the National Quality Foundation (NQF)

» Acute Myocardial Infarction» Heart failure» Pneumonia

http://www.santarosaconsulting.com/santarosateamblog/post/2012/03/29/an-early-look-at-hospital-readmissions-reduction-program

Reimbursement Penalties

• 2,211 American hospitals received reimbursement penalties on Oct 1, 2012 for high readmission rates – Together they will forfeit about $280 million in Medicare funds over next year

• According to Medicare, 2 out of 3 hospitals evaluated failed to meet its new standards for preventing 30 day readmissions.

• (penalty rate up to 1%) x (total Medicare reimbursement/yr) = lost revenue

Rau, Jordan. Kaiser Health News. “Medicare to Penalize 2,211 Hospitals for Excess Readmissions”. Aug 13-12.

Re-hospitalizations among patients in the Medicare Fee-for-service Program

• New England Journal of MedicineStephen F. Jencks, MD, MPH, Mark Williams, MD and Eric A Coleman, MD MPH.

Abstract • I in 5 Medicare beneficiaries are readmitted within 30 days

– Which equates to 2.3 million patients• National cost of over $17 Billion • Half of patients readmitted had no physician contact• 70% of surgical readmits were for chronic medical conditions.• Potentially 40% of all Readmissions are preventable

Readmission Factors

• AARC webcast August 28-12 “Hospital to Home-efforts at Reducing Hospital Readmissions”. Greg Spratt BS, RRT; Kimberly Wiles BS, RRT; Becky Anderson RRT.

• 69% were non compliant with meds• 51% lacked knowledge: How to use Therapy Devices• 45% inadequate knowledge of medications• 42% unable to self manage care• 37% had no follow up visit with Physician• 31% develop infection post discharge

Readmissions Not The Only Change

NO MORE FEE FOR SERVICE

• Pay for Performance (P4P) =Value Based Purchasing(VBP)

• Rewards physicians, hospitals, medical groups and other health care providers for meeting certain performance measures for quality and efficiency

• Rewarding hospitals for the quality of care they provide to Medicare patients, not just the quantity of procedures they perform

• Also eliminating payments for “never events”

http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/hospital-value-based-purchasing/Downloads/FY-2013-Program-Frequently-Asked-Questions-about-Hospital-VBP-3-9-12.pdfFind article in my favorites: Readmission 2012 and it has CMS and frequently asked questions.

Hospital Performance

• Value Based Purchasing Program (VBP)– Begin to pay hospitals for their actual performance

• Requires portion of Medicare reimbursement to be withheld and returned proportionate to how the Hospital performs

30%

25%

45%

3 Categories

Patient ExperienceOutcome MeasuresClinical Processes

Value-based Purchasing:What Hospitals and Healthcare Systems Need to Know Now to Manage Their Medicare Dollars

Pat Bickley, Jude Odu-Health Care Dataworkswww.HCD.com

Changing Reimbursement

Fiscal Year Value Based Purchasing

Hospital Readmission Reduction Program

Hospital Acquired

Conditions

Total

2013 1.00% 1.00% 0 2.00%

2014 1.25% 2.00% 0 3.25%

2015 1.50% 3.00% 1.00% 5.50%

2016 1.75% 3.00% 1.00% 5.75%

2017 2.00% 3.00% 1.00% 6.00%

.

Alexander, K.,LHA Legislative & regulatory Update. LA Assn for Healthcare Quality Annual Education Conference, April 2012

Payment Reform for Hospitals

Patient Satisfaction ‐ HCAHPS

Some of the 20 Key Performance Measures:

• Nurse communication• Cleanliness and quiet• Doctor communication• Responsiveness of hospital staff• Pain management• Discharge information• Communication about medications• Overall rating of hospital

http://www.mdahq.citymax.com/f/nikolas_matthes.pdf slide 16 of PP presentation listed:Value‐based Purchasing

Higher Per Capita Spending Doesn’t Translate into Higher Life Expectancy

Source: 2006 CIA Fact Book Life Expectancy-Per Capita Spending

AARC Hospital to Home Program

• AARC did a survey in September 2011• 36% of hospitals do nothing to help COPDers• 42% us EBM algorithms, pathways, guidelines or protocols• 20% of COPD programs inpatient, discharge, and outpatient

needs• 12% partner with DME’s• 5.7% had RT Case Managers or discharge planners• 2.6% had COPD coordinator positions

Time For Disease Management

• COPD was predicted to be #3 cause of death by 2020• It reached this milestone in April 2011 according to CDC

• Population >65 will increase 73% by 2025– Baby Boomers are over 80 million strong.

• PCP shortages of 20-27% by 2025.– Allergists, PCP, anesthesiologists.

• There are over 100 Million patients in the US

classified as having chronic conditions

Kallstrom, T. “The Long Term Implications of the Affordable Care Act”. AARC Times, Oct 2012. pg 20-21

Pulmonary Issues Aren’t Going Away!

RT as a Physician Extender• Work in PCP office assessing patients

RT as Case Managers• Teach self management• Modify patients behavior at home• Coach, encourage and give advice• Regular communication between patient and RT• Identify unmet health needs• Keeps patients:

– Out of Hospital– Out of ED– Out of Physician office

HARP(Hospital admissions risk program)

• Melbourne, Australia study• Patient focused and self management of care through acute

and community health sectors

Case Managed COPD Control Group

ED Visits 10% ED Visits 45%

Admits 25% Hosp Admits 41%

Hospital LOS 18% Hosp LOS 51%

Bird, S et al. “An integrated Care Facilitation model Improves QOL & reduces use of Hosp resources by pts w/ COPD & CHF”. 2010:16(4):326-33.

Likely Contributors to the High Rates of Readmission

1. DRG’s– Lump payment given by Medicare based on diagnosis– Doesn’t look at the level of service given to patient.– To much incentive to deliver care at or below DRG Rate– Pt gets discharged before medically appropriate to do so

2. Lack of communication between hospital healthcare professionals, Home Care Physicians etc.– Leads to conflicting and additional care

Both can increase the chance the Patient gets readmitted!

http://www.healthreformgps.org/resources/hospital-readmissions-reduction-program/

It will take a village!

Two areas of fragmentation of Care

a) Hospital Communication between Physician, RN, RRT, OT, PT, Social Work

etc

b) Various Other Industries Hospitals, Sniff, LTAC, Rehabilitation, Office Physician, Home Care

services, Hospice etc

• It will take a village to solve the problems of readmission• We cannot work and manage these patients in isolation

Areas for Change in Potentially Preventable Readmissions

Improve Quality Of Inpatient Care1. Education

– Choose a champion – Customize patient education – Use teach back regularly

•especially with regard to understanding discharge instructions– Teach patient self Managed Care– Involve different disciplines to teach

•For example RRT required to teach respiratory methods

Currently an average of 8 minutes is spent on education of our patients in the hospital!

• We don’t get reimbursed on education

http://www.ama-assn.org/amednews/2011/02/07/prsa0207.htm

Making it Work?

• Piedmont Hospital, Atlanta– 481-bed, acute-care hospital

• After implementing changes:– <70yr olds had readmission rates

of 13.05% before & after 3.97% – >70yr olds had rates of 15.9% before,

which fell to 11.2%

**And Their Length of Stay dropped **

http://www.ama-assn.org/amednews/2011/02/07/prsa0207.htm

How They did it?

Medication Reconciliation

• 2/3 of readmissions have something to do with medications

• Pharmacist responsible for drug review with patient/family/PCP

Identify patient at high risk for Readmission

Ensuring good follow up care• Hospital secretary

schedules Dr Appt for patient and insist they be seen w/in 2 weeks

Patient follow up phone call within 72hrs of discharge:

• Why were they in hospital?

• Symptoms they should be looking for.

• What Medications they are taking ?

• When is next Dr appt.?

Patient PASS (keep it in their wallet)

• Single sheet form that lists:

• Reason for hospitalization• Medical appts• Issues to discuss with

PCP

http://www.ama-assn.org/amednews/2011/02/07/prsa0207.htm

What’s Wrong with this Picture?

Source: Fischbeck, Paul. “US-Europe Comparisons of Health Risk for Specific Gender-Age Groups.” Carnegie Mellon University; September, 2009

“Hospital-acquired infections kill 99,000 Americans each year.”

• “That’s equivalent of a jumbo jet full of passengers crashing every other day.¹”

• 35,967 Deaths Annually from Hospital-Acquired Pneumonia²

1www.safepatientproject.org2Nicolau et al. “Redefing Success for VAP: 360-Degree approach”, JMCP June 2009, Vol. 15, No. 5

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Push Forward

• Therapist Driven Protocols• Patient Outcomes aligned with VBP• Member of the Care Continuum• Patient Advocate; Access to RT care• Education Specialist for COPD/Pneumonia Population• Heighten AWARENESS of the Hospital staff that RT’s are a valuable

clinical resource• Airway clearance is a main player in keeping pt out of the hospitals• Finding devices and techniques that can follow the patient home will

become more and more important

Areas for Change in Potentially Preventable Readmissions

Improve Quality Of Inpatient Care cont’d…2. Multidisciplinary rounds

1. Scheduled communication times to discuss patient as a team

2. Set up a discharge plan that is looked at and signed off on by all disciplines

RRT should always be involved with chronic lung pt discharge plan

3. Use Pulmonary Rehabilitation Facilities3. Within 3 days of discharge

4. Teach and explain medications and lifestyle changes, exercises etc It is shown when pts go to an LTACH before they go home there are

three times fewer readmission bounce backs

4. Establish follow up plan before discharge5. Provide pt meds at discharge

6. Have a dedicated advocate/coach for pt at discharge and beyond

Areas for Change in Potentially Preventable Readmissions

5. Early post discharge follow up– Remote monitoring/telehealth

• It was shown that an RN or RRT giving patient education over the phone reduced hospital admissions by 40% and ER visits by 41% for COPD patients.1

6. Reconciliation of Medication– Piedmont Hospital In Atlanta

• Improving their process fixed a 46% discrepancy rate.1

7. Need Proactive Thinking rather than Reactive – There is a lack of preventative healthcare– Symptoms treated, not the root cause

1. J. Bourbeau, M. Julien, et al, “Reduction of Hospital Utilization in Patients with Chronic Obstructive Pulmonary Disease: A Disease-Specific Self-Management Intervention,” Archives of Internal Medicine 163(5), 2003. S2. http://www.ama-assn.org/amednews/2011/02/07/prsa0207.htm

Proactive Not Reactive Respiratory Issues from Retained Secretions

Proactive Behavior

Could result in:

Prevention of respiratory complications

Faster weaning

Decreased ICU/ Hospital LOS

Improved morbidity/

mortality

Health

care Savings

Discharge planning involvement

Early intervention with lung expansion and/or airway clearance therapies

Routine Assessments

Communicate and Educate

Patient as active member of the team

Respiratory Protocols

• DASH is a Homecare Respiratory Services program– Driven by novel respiratory software, protocols & improved reporting– Begins prior to discharge

• Risk evaluation• COPD order set includes DASH (Risk evaluation, Assessment & transition)

28% readmission in Philadelphia for COPD pts

Incorporation of DASH has reduced it to <4%

DASH= Discharge + Assessment & Summary @ Home

http://homecaremag.com/provider_profiles/chronic-disease-management-201105

DASH

• COPD/CHF/Pneumonia all require specialization• Early on: < 10% were coming home with a follow up appointment• Now 90% get a follow up appt

– RT calls them at home and sets up appt with them

Changed Name from the Pulmonary Rehabilitation clinic to “COPD Independence Program”

Systematic Assessment and Early Intervention

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Role of Respiratory Therapist in Re-Admission Prevention

• RT’s stepping up and taking an active roll – Properly assessing and identifying patients at risk for retained secretions– Providing Patient Education– Ensuring proper follow-up after discharge– Assessment of needs at discharge

• Effective Communication with:– Discharge Planner– Nursing– Physician– PT / OT– Homecare /transitional care RT– DME companies / vendors

Closing the gap between hospitals, extended care and homecare by working as a team!

For Best

Patient Outcomes

Physicians PA’s & NP’s

Respiratory Therapists

Nurses

PT/OT & Speech

Discharge Planners &

Case Managers

Post Acute Care Team

Manufacturers Distributors

Insurance Companies & other payers

Taking the Team Approach…

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Comparing Hospitals

Conclusion

• Health care reform is here and Respiratory Care both home and hospital based need to position themselves as invaluable.

• The causes of Readmissions span multiple providers along the whole continuum of patient care.

• Many of the solutions to these problems are in front of us. Now its up to us.